Healthcare Provider Details

I. General information

NPI: 1265081301
Provider Name (Legal Business Name): THE TRAUMA AND ADDICTION TREATMENT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 EXPLORER CT
FRANKLIN IN
46131-6982
US

IV. Provider business mailing address

3270 E 17TH ST # 261
AMMON ID
83406-6758
US

V. Phone/Fax

Practice location:
  • Phone: 208-534-8303
  • Fax:
Mailing address:
  • Phone: 208-534-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW SMITH
Title or Position: CEO
Credential:
Phone: 208-534-8303